Based on record review, staff interview, and policy review, the facility failed to implement policies and procedures to ensure antibiotics were not used without the presence of a diagnosed infection and failed to complete an infection screening evaluation for one of three residents (Resident (R) 137) reviewed for antibiotic stewardship. The failure had the potential to increase the risk of adverse events, including the development of antibiotic-resistant organisms, resulting from unnecessary or inappropriate antibiotic use. …
F881 citations in Delaware
Antibiotic stewardship · Infection Control Deficiencies
Implement a program that monitors antibiotic use.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Delaware cites F881 more often than its own record predicts
1.33 times the share F881 takes of citations nationally.
Of every deficiency written in Delaware in 2025, this is the portion that was F881.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Delaware surveyors wrote
F881 findings written in Delaware, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on policy review, record review and interview, it was determined that the facility failed to conduct an ongoing review of antibiotic stewardship. Findings include: Review of the undated facility Antibiotic Stewardship policy revealed, #1: Antibiotic stewardship is part of our infection prevention program. Review of the 12/2022 revised facility Infection Control Program policy revealed: The Infection Prevention and Control Officer responsibilities include: The nursing staff maintains the 24-hour report which lists the residents on antibiotics. …
The short window
Recent years
| Year | Share of Delaware citations | vs expected |
|---|---|---|
| 2023 | 0.53% | 1.14× |
| 2024 | 0.35% | 0.78× |
| 2025 | 0.64% | 1.33× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Delaware surveyors cite →
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